Case Management Utilization Review Documentat

Job description

MACON COMMUNITY HOSPITAL
Position Description
Department Name:
Care Management
Employee Name:
Job Title: Case Management/Utilization Review/Documentation Specialist
Effective Date:
Reports to (Title): Care Management Director
Supervises:
(Positions)
N/A
I have reviewed these job requirements and verify that I can perform all essential functions of this position. I understand that information regarding patients at this facility is confidential and is not to be disclosed without written authorization of the patient or authorized representative. I will discuss patient’s information only in the course of my duties and never in open areas such as hallways, snack bar, etc., where it might be overheard by visitors or other patients, or outside of the hospital while off duty. I also understand that information in some patient’s records may be governed by federal regulation and that disclosure of such information is punishable by fine or imprisonment, even after I leave the employment of the facility. I certify that I have completed HIPAA training and will honor all policies and procedures. I understand that violations of these policies and procedures may result in sanctions. I agree to abide by all local, state and federal laws.
Employee Signature Date:
• Position Summary

Case Management :
Collaborates with interdisciplinary healthcare team members, patients, families, providers, payers, and external service organizations to coordinate care and support optimal patient outcomes.
Conducts comprehensive assessments of patient care needs, psychosocial barriers, discharge needs, and available support systems to facilitate individualized care planning and appropriate resource utilization.
Coordinates and facilitates timely, safe, and effective discharge planning, including referrals to post-acute providers, community resources, home health services, rehabilitation services, and other appropriate levels of care.
Leads or facilitates interdisciplinary rounds and discharge planning meetings to review patient progress, anticipated discharge dates, barriers to discharge, care coordination needs, and opportunities to improve patient flow.
Promotes effective communication among the interdisciplinary team regarding patient status, medical necessity, clinical documentation, care progression, and discharge readiness.
Identifies barriers to care progression and collaborates with physicians, nursing, ancillary departments, patients, families, and external partners to develop and implement appropriate solutions.
Supports the development, implementation, and evaluation of clinical pathways, care coordination protocols, and processes designed to improve quality, efficiency, and continuity of care.
Collaborates with nursing leadership and other appropriate clinical leaders to address clinical care concerns within established roles, policies, and escalation procedures.
Participates in quality improvement, performance monitoring, and evaluation activities related to case management, patient flow, discharge planning, resource utilization, and patient outcomes.
Assists with social services and discharge planning needs.
Utilization Review:
Performs admission and concurrent utilization reviews using applicable medical necessity criteria, clinical guidelines, payer requirements, and hospital policies to evaluate the appropriateness of admission, level of care, and continued hospitalization.
Evaluates medical necessity, patient status, length of stay, treatment provided, and utilization of hospital and physician services to support appropriate resource allocation and quality patient care.
Collaborates with attending physicians, nursing, and other appropriate team members to resolve questions regarding admission status, level of care, medical necessity, and continued-stay criteria.
Identifies cases that do not meet established criteria or require further review and escalates concerns promptly to the appropriate physician advisor, clinical leader, or designated decision-maker.
Monitors length of stay, avoidable days, delays in care progression, and other utilization indicators to identify opportunities for improvement.
Supports the prevention, tracking, and resolution of payer denials related to medical necessity, patient status, level of care, and length of stay.
Coordinates and supports the denials/appeals process, including timely submission of supporting clinical documentation, preparation of records, communication with payers, and coordination of peer-to-peer reviews as appropriate.
Maintains accurate and timely utilization review documentation, review logs, payer communications, and other records necessary to support compliance and operational reporting.
Evaluates utilization trends and collaborates with hospital leadership to identify opportunities to improve efficiency, reduce avoidable utilization, and maintain appropriate standards of patient care.
Assists with continuity-of-care planning and discharge coordination in collaboration with the care management team..
Swing Bed:
Coordinates swing bed referrals and evaluates referral information to determine whether patients appear to meet applicable program eligibility, clinical, and facility admission criteria.
Coordinates clinical record review and interdisciplinary evaluation of potential swing bed admissions in accordance with applicable requirements and hospital policies.
Obtains and coordinates required payer authorizations and communicates with insurance representatives regarding coverage, authorization status, continued-stay requirements, and discharge planning.
Communicates with referral sources, providers, patients, and families regarding swing bed admission requirements, care needs, anticipated transitions, and discharge arrangements.
Monitors continued eligibility, medical necessity, and documentation requirements throughout the swing bed stay, as applicable.
Coordinates discharge planning and transitions to the next appropriate level of care in collaboration with the interdisciplinary team.
Maintains accurate referral, authorization, and review documentation and identifies barriers to admission, continued stay, and discharge.
Monitors swing bed referral activity, admission outcomes, authorization issues, and other relevant performance indicators to identify opportunities for process improvement.
Clinical Documentation Review:
Performs concurrent and retrospective review of inpatient records and identifies opportunities to improve quality of documentation.
Communicate with providers to promote accurate and complete documentation of diagnoses and/or procedures in the health record.
Generates compliant, clinical queries for clarifying Principal Diagnoses, Secondary Diagnoses, Procedures, Severity of Illness (SOI), Risk of Mortality (ROM) and Quality Indicators.
Provides clinical support for Coding Team and performs clinical validation. Collaborate with Providers, Case Managers, Coding Team and Health Information Management Professionals to ensure coding accuracy, and address DRG discrepancies.
Provides clinical documentation education to Hospital Leadership, Physicians, Clinicians, Coders and Health Information Management Professionals to improve documentation quality and to optimize quality of patient care.
Creates reports summarizing identified trends, variances, analyses, and CDI impact.
Participates in meetings with Hospital Leadership, Department Chairs, Division Chiefs, Physicians, Clinical Teams, Coding Teams and Health Information Management Professionals to provide feedback and suggestions for improvement of documentation quality.
Other:
This position also coordinates the Peer Review function.
This position is in person/on-site position.
II. Position Requirements:
• Licensure/Certification/Registration: Certification preferred in Case Management. Certification in Utilization Review or Utilization Management preferred. CDIP, CCDS or CCS, CCA credential preferred. If employee does not hold one of the previously mentioned licenses/certificates, registration is completed within six months of hire and completions/certification is gained within two years of hire. Current registered nursing license in the State of Tennessee.
• Education: High School diploma, medical terminology, anatomy and physiology, training with Interqual criteria. Graduate from accredited school of nursing. BSN preferred.
• Experience: 2-3 years experience in health care facilities. Preferred experience in Case Management, Acute Inpatient Hospital, and Utilization Review.
• Special qualifications: Strong communication skills including the ability to communicate in a positive manner, verbally and in writing. Self-motivated, independent, professional, creative and dependable. Ability to function without supervision and to work with difficult personalities and situations within guidelines. Able to merge clinical and financial processes. Ability to work with others as a team.

III. Degree of Supervision Required: The Case Manager is expected to perform most job duties independently and in accordance with established departmental and hospital policies/procedures.
IV. Ages of Patients Served: This position requires competence in assessment, treatment, and/or care for the age groups indicated. The staff member must be able to demonstrate the knowledge and skills necessary to provide care, based on physical, educational, safety, and related criteria, appropriate to the age of the patients served. The skills and knowledge needed to provide such care may be gained through education, training, or experience.